What is the relationship between pancreatitis and cholelithiasis (gallstones)?

From the Guidelines

Gallstones are a major cause of pancreatitis, and cholecystectomy during the initial admission is recommended to prevent recurrent episodes of acute pancreatitis. The mechanism by which gallstones cause pancreatitis involves the temporary blockage of the pancreatic duct opening by gallstones that have passed from the gallbladder into the bile duct, leading to inflammation and potential damage to the pancreas 1. Gallstones form when substances in bile, such as cholesterol or bilirubin, crystallize and harden, with risk factors including obesity, rapid weight loss, high-fat diet, female gender, pregnancy, certain medications, and genetic predisposition 1. Symptoms of gallstone pancreatitis typically include severe upper abdominal pain radiating to the back, nausea, vomiting, and fever. Treatment usually involves hospitalization with bowel rest, IV fluids, pain management, and often antibiotics if infection is present. Once the acute inflammation resolves, cholecystectomy during the initial admission is strongly recommended to prevent recurrence, as it can substantially reduce the risk of mortality and gallstone-related complications 1. In some cases, ERCP may be needed to remove stones from the bile duct before gallbladder surgery, particularly for patients with associated cholangitis or persistent biliary obstruction 1. Key considerations in the management of gallstone pancreatitis include:

• Prompt recognition and treatment of the condition to prevent complications
• Cholecystectomy during the initial admission to prevent recurrent episodes
• Potential need for ERCP in certain cases
• Importance of addressing risk factors for gallstone formation to prevent future episodes.

From the Research

Cause of Pancreatitis and Gallstone

• Gallstone pancreatitis (GSP) is the leading cause of acute pancreatitis, accounting for approximately 50% of cases 2
• Gallstones account for the majority of acute pancreatitis in the Western world, with an increase in number and smaller size of the stones increasing the risk for biliary pancreatitis 3
• Gallstone disease is the most common cause of acute pancreatitis in the Western world, with severe disease occurring in about 20% of cases and associated with significant mortality 4

Relationship Between Gallstones and Pancreatitis

• Gallstone pancreatitis is usually related to small stones, which may not be detected by conventional cholecystographic techniques 5
• Occult microlithiasis is a common cause of idiopathic acute pancreatitis, and can be detected by biliary drainage and microscopic examination of centrifuged duodenal bile 5
• The presence of gallstones can be indicated by trans-abdominal ultrasound and elevated serum alanine transaminase, and can be confirmed by endoluminal ultrasonography 6

Implications for Management

• Patients with gallstone pancreatitis should undergo cholecystectomy to prevent future recurrence, with the timing of the procedure depending on the severity of the disease 2, 3
• Endoscopic retrograde cholangiopancreatography (ERCP) may be necessary for patients with suspected cholangitis or biliary obstruction, but is not routinely recommended 2, 3
• Intraoperative cholangiography may be useful in detecting choledocholithiasis, but its routine use is not recommended 2
• Patients who are not fit for cholecystectomy may undergo prophylactic endoscopic sphincterotomy to prevent further attacks 6